Background: Severe acute malnutrition (SAM) is a major public health concern in India, contributing significantly to childhood morbidity and mortality. This study aimed to identify socio-demographic and clinical risk factors associated with SAM among children aged 6–59 months in an urban locality of South India. Methods: A case-control study was conducted among 100 children, comprising 33 cases with SAM and 67 age-matched controls. Data on socio-demographic factors, birth history, and feeding practices were collected using a structured questionnaire. Anthropometric measurements were recorded to confirm nutritional status. Statistical analyses included chi-square tests and logistic regression to determine associations. Result: Children from joint families were 3.92 times more likely to develop SAM (p < 0.001). Low birth weight was a significant predictor (OR: 6.04, p < 0.001). Pica was highly associated with SAM (OR: 13.91, p < 0.001). Bottle feeding and poor appetite also showed notable associations. Maternal education and socioeconomic status emerged as key determinants, with lower education levels and lower socioeconomic classes significantly linked to SAM prevalence. Conclusion: The study identifies modifiable socio-demographic and clinical risk factors contributing to SAM. Addressing these determinants through targeted public health interventions is crucial to reducing the burden of malnutrition in urban India.